Herzog, Tyler L.

Abstract Introduction Sleep apnea impacts 50-70% of patients following stroke. Treatment of obstructive sleep apnea (OSA) in patients with stroke using continuous positive airway pressure (CPAP) has been recommended in recent American Heart Association/American Stroke Association guidelines. However, stroke patients poorly tolerate CPAP and often remain untreated. There is a paucity of data regarding alternative treatments such as oral appliance therapy (OAT) in stroke patients. We hypothesized that oral appliance therapy would be an efficacious option in the treatment of OSA in stroke patients, defined as a ≥50% reduction in apnea-hypopnea index (AHI) or oxygen desaturation index (ODI) or reduction in total AHI or ODI to < 10/h. Methods We performed a retrospective review of patients with OSA treated with OAT at our institution and had a history of stroke prior to receiving the oral appliance. Chart abstraction included demographic data, stroke type, sleep apnea diagnostic data, and efficacy data. Efficacy data included repeat sleep studies, overnight oximetry, patient reported outcomes, and subjective benefit, as available. Results 23 patients (52% female, mean age 63) were identified with a history of stroke prior to use of OAT for OSA. Baseline parameters (mean, SD) included BMI (30.8, 4.2), AHI (15.0, 10.6), and Epworth Sleepiness Scale (ESS) (9.3, 5.4). Post-treatment parameters included (mean, SD) BMI (30.1, 4.2), AHI (12.4, 12.0), and ESS (6.5, 4.0). 12 patients had both baseline and follow-up sleep studies performed which met criteria for AHI efficacy of OAT in 7 of 12 (58%). Wilcoxon signed rank exact test demonstrated improvement in median AHI of 9.3 (0.40-17.6, p< 0.05) among these 12 patients. 2 of 3 (67%) patients with overnight oximetry follow-up met criteria for ODI efficacy of OAT. Of 8 patients with only subjective follow-up, 6 (75%) reported subjective improvement and 2 (25%) did not tolerate the device. Conclusion This study demonstrated that oral appliance therapy is efficacious in reducing the AHI by at least 50% or to a value below 10 in a majority of patients. Oral appliance therapy may be a viable alternative to CPAP in selected OSA patients with a history of stroke. Support (if any) No support

Abstract Rationale Global Lung Function Initiative (GLI) Global spirometry reference equations were recently derived to offer a “race-neutral” interpretation option. The impact of transitioning from the race-specific GLI-2012 to the GLI Global reference equations is unknown. Objectives Describe the direction and magnitude of changes in predicted lung function measurements in a population of diverse race and ethnicity using GLI Global in place of GLI-2012 reference equations. Methods In this multicenter cross-sectional study using a large pulmonary function laboratory database, 109,447 spirometry tests were reanalyzed using GLI Global reference equations and compared with the existing GLI-2012 standard, stratified by self-reported race and ethnicity. Measurements and Main Results Mean FEV1 and FVC percent predicted increased in the White and Northeast Asian groups and decreased in the Black, Southeast Asian, and mixed/other race groups. The prevalence of obstruction increased by 9.7% in the White group, and prevalences of possible restriction increased by 51.1% and 37.1% in the Black and Southeast Asian groups, respectively. Using GLI Global in a population with equal representation of all five race and ethnicity groups altered the interpretation category for 10.2% of spirometry tests. Subjects who self-identified as Black were the only group with a relative increase in the frequency of abnormal spirometry test results (32.9%). Conclusions The use of GLI Global reference equations will significantly impact spirometry interpretation. Although GLI Global offers an innovative approach to transition from race-specific reference equations, it is important to recognize the continued need to place these data within an appropriate clinical context.

Abstract Background The medical intensive care unit (MICU) offers rich resident learning opportunities, but traditional teaching strategies can be difficult to employ in this fast-paced, high-acuity environment. Resident perspectives of learning within this environment may improve our understanding of the common challenges residents face and inform novel approaches to transform the MICU educational experience. Objective We conducted a qualitative study of internal medicine residents to better understand their approach to learning the critical care activities that they are entrusted to perform in the MICU. Methods Using a thematic analysis approach, we conducted six focus group interviews with 15 internal medicine residents, separated by postgraduate year. A trained investigator led each interview, which was audio-recorded and transcribed verbatim for analysis. Our diverse research team, representing different career stages across the continuum of learning to minimize interpretive bias, identified codes and subsequent themes inductively. We refined these themes through group discussion and sensitizing social learning theory concepts using Wenger’s community of practice and organized them to create learner archetypes and a conceptual framework of resident learning in the MICU. Results We identified three thematic resident learning categories: learning goals and motivation, clinical engagement, and interprofessional collaboration. We distinguished three learner archetypes, the novice, experiential learner, and practicing member, to describe progressive resident development within the interprofessional MICU team, the challenges they frequently encounter, and potential teaching strategies to facilitate learning. Conclusion We developed a conceptual framework that describes the resident’s journey to becoming a trusted, collaborating member of the interprofessional MICU team. We identified common developmental challenges residents face and offer educational strategies that may support their progress. These findings should inform future efforts to develop novel teaching strategies to promote resident learning in the MICU.